INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Servces was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report Form completed by the facility on October 20, 2015, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on November 19, 2015. The form listed five counselors and a clinical supervisor as clinical staff.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40 hours), and the total number of clients assigned to the following employees on November 19, 2015, employees # 4, 7 and 8 exceeded the allowable maximum 35:1 caseload.
Counselor # 4 had an FTE caseload of 78:1
Counselor # 7 had an FTE caseload of 39:1
Counselor # 8 had an FTE caseload of 41:1
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
OP Addictions Counselors will not exceed 35:1 ratio. OP will hire another Full-Time Addictions Counselor to replace the Full-Time Addictions Counselor who left without giving required notice. Caseloads for Addictions Counselors have been decreased.
Starting December 1 the census has decreased and part time clinical staff hours have been adjusted so that we are now in compliance with the state standard.
The staff to patient ratios are measured quarterly by the senior director of outpatient services and are adjusted accordingly.
The Senior Director of Outpatient Services is responsible for compliance.
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705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, the facility failed to light interior exits and stairs at all times.
The finding include:
A physical plant inspection was completed on November 19, 2015 at 8:25 am.. At the time of the inspection, the set of stairs leading to the first landing in the interior stairwell exit from the 2nd floor hallway by office 203, did not contain operable lighting.
These findings were reviewed with the facility staff during the physical plant inspection.
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Plan of Correction
The light bulbs that were out were replaced the same morning as the inspection. The exits and stairwells will be lit at all times and it will be monitored starting Nov. 19, 2015 as part of the daily building checklist by Outpatient staff.
The Senior Director of Outpatient will be responsible for Compliance.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a personal history and psychosocial evaluation in one of eight client records, and a preliminary treatment and rehabilitation plan in one of eight client records reviewed.
The findings include:
Eight client records requiring documentation of a personal history, a psychosocial evaluation, and a preliminary treatment plan were reviewed on November 19, 2015. A personal history and psychosocial evaluation was not completed in client record # 4 and a preliminary treatment and rehabilitation plan was not completed in client record # 6.
Client # 4 was admitted on November 5, 2015 and is still an active client. A personal history and psychosocial evaluation were not documented during the intake process in the client's record as of the date of the licensing inspection.
Client # 6 was admitted on April 2, 2015 and was discharged on June 22, 2015. A preliminary and rehabilitation plan was not documented in the client's record as of the date of client # 6's discharge date.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
A personal history and psychosocial evaluation will be completed on all clients admitted into an OP program. This will be monitored monthly during chart reviews by the Team Leader.
The preliminary treatment plan will be completed on all clients admitted into an OP program. This will be monitored during monthly beginning Nov. 20, 2016 chart reviews by the Team
Leader.
The Senior Director of Outpatient will be responsible for Compliance.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in two of two client records. Additionally, the facility did not provide the type and frequency of treatment and rehabilitation services in two of four outpatient activity client records reviewed.
The findings include:
Four outpatient activity client records were reviewed on November 19, 2015. All were reviewed for individualized treatment and rehabilitation plans which are to be developed with the client. The treatment plans also lacked the type and frequency of treatment and rehabilitation services.
Client #1 was admitted on May 1, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on July 29, 2015. The treatment plan was not signed by the client and lacked the type and frequency of treatment and rehabilitation services..
Client #4 was admitted on July 13, 2015 and their individualized treatment and rehabilitation plan was developed and signed by staff on September 25, 2015. The treatment plan was not signed by the client and lacked the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The type and frequency of treatment and rehabilitation services will be included in all client individualized treatment and rehabilitation plans. All clients will develop their individualized treatment and rehabilitation plan during their psychosocial evaluation. The Addictions Counselor will document that the client?s individualized treatment and rehabilitation plan was developed with the client in a progress note. This will be monitored during monthly chart reviews by the Team Leader beginning Nov.20.
The Senior Director of Outpatient will be responsible for Compliance.
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